By prof dr Corstiaan Breugem Head Pediatric Plastic Surgery Amsterdam UMC President Interplast Holland, Dutch Cleft Palate Craniofacial Association, and vice president European Cleft Palate Craniofacial Association

I recently supervised a senior resident’s surgery without setting foot in the operating room. The resident was wearing remote surgical assistance glasses, which allowed me to follow his every move in real time from the next room over.

I decided early on in the procedure that I was going to give him as little advice as possible. If I saw that he was making a laborious move, I would offer a suggestion, but I would otherwise do my best to keep quiet.

It seemed like a simple choice, but the resident approached me afterwards to let me know just how rewarding the surgery was as a result. He spoke to the comfort of knowing that I was close by – paired with the freedom of operating independently. It really struck a chord with me.

Typically, as the senior surgeon in the operating room, we are physically in the operating room – and we don’t always realize how much we impact the resident’s decisions. Whether it’s small comments or even subtle body language, we influence their every move.

This particular surgery wasn’t easy, but it was a procedure that the senior resident was more than capable of doing on his own. Yet he wouldn’t usually be afforded that opportunity.

A New Perspective On Teaching

The experience afforded me a new perspective in more ways than one. Not only did I see the value in giving our residents greater autonomy, but it also gave me an incredible vantage point from which to oversee the young doctor’s work.

Regardless of what surgery or procedure you’re learning, the steps are the same: read the textbook, watch a senior surgeon, try it yourself. But when you’re in the passenger seat – either as the student or the OR supervisor – you’re watching from a 90-degree angle, hovering beside the acting surgeon and looking over their shoulder.

To solve this we started putting a camera in our operating lamps, but often the angle would be wrong and someone’s head or shoulder would block the operation. Having the perfect line of sight into what the operating surgeon is doing changes the game entirely. While it won’t do away with textbook learning altogether, it certainly offers a quicker way for students to grasp the anatomy, the embryology, the surgical procedures, and the subjective decisions made along the way.

When I look at a cleft lip, there are so many things that you cannot explain from a textbook or a photograph. We are solving three-dimensional problems, and it’s time we had the technology to support that. The extension of a skin incision by 1-2 mm, or releasing a muscle 2 mm more, can make a huge difference in terms of the outcome.

Although providing teaching to residents is paramount for me, teaching medical students is also important. During surgery this is not always possible due to the focus on residents. Moreover medical students watch each operation from a distance, while the resident will stand next to me. However, with surgical assistance glasses medical students can follow the surgery in real time – “live” – and can better understand the discussions the surgeons performing the “hands-on” surgery have. They can also ask questions.

Continuous, Compound Learning

Of course, learning isn’t only the job of the student – medicine really is lifelong education. Since there’s no such thing as perfection in our field, there is always room for improvement; a mindset most physicians have embraced.

Just like the residents we supervise, we all make subjective split-second decisions throughout a given procedure. Imagine you could go back, review your decisions, and determine how you would respond differently in the future, taking some of the subjectivity out of a future operation? In this way, remote assistance serves as a tool for all of us on this road to continuous improvement; a means to quality-assess our own work.

The surgery smart glasses technology can be used in many other departments in the hospital. Consider how the same benefits could scale if this technology were made available not only in the OR but also in the ICU, emergency room, during consultations, and in ward touring.

In this way we could embrace the concept of continuous learning – to keep our minds active, spark intelligent debate, and encourage thoughtful consideration and post-operative assessment in different scenarios.

More Benefits To Come

The value of remote assistance was amplified by COVID-19, but I don’t think there’s any doubt that this kind of technology will continue to improve surgical outcomes long beyond the current pandemic. The potential for surgical smart glasses technology to lead to better, more accurate surgeries is relatively indisputable – and the upsides are significant:

• Better planning potential Increased planning pre-surgery would allow you to use your operating time much more effectively. We are already looking at how tech like 3D photography will help you determine where to make your incision. But imagine if, using footage of previous cases, we were able to review similar operations that were captured in detail up closely. Using surgical smart glasses, we would be able to get an even better perspective.

• Decreased surgery times With better planning and more efficient procedures comes decreased time in the OR. I anticipate that we will soon have several ways to locate muscles, blood vessels, and more in advance of a surgery, in order to move even more of the decision making process to low-stress, pre-op time – and ensuring better communication during surgery using technologies like surgical smart glasses.

• Enhanced healthcare around the world Having worked with Interplast Holland to help train physicians in low-income countries, I’ve seen just how important it is for learning to be in real time and for support to be accessible from anywhere – during the COVID-19 pandemic and beyond.

• Heightened surgical standards I’ve noted how remote assistance technology offers an opportunity to QA your own work, but I can envision a future where formal quality control is taken to a new level. Medical associations could evaluate surgeons every few years on how well they still perform a certain procedure, placing certification emphasis back on role proficiency versus meeting attendance.

• Sustainable medical meetings Meetings have always been a place to meet colleagues and discuss difficult cases. These glasses could be a great way to minimize our CO2 footprint, as traveling will be reduced. Teaching can also be enhanced with high-quality videos.

• Support during difficult cases Help in our consultation process when confronted with difficult cases – such as during calls at the Emergency Department. In this way, the residing resident could consult with his supervisor specialist, who most probably will be at home and unnecessary rounds or visits to AE departments could be prevented.

Choosing A Student’s Mindset

At the end of the day, the greatest value remote technology brings to the medical field is its ability to supplement learning – but these learning opportunities span far beyond a traditional professor/student relationship. As physicians, we must stay curious and committed to furthering our education every day – and technology is the obvious conduit.

While COVID-19 has helped expedite technology adoption across categories, I truly believe this adoption is here to stay long after physical distancing mandates demand virtual solutions. The technologies that will be most impactful are those that, like the Rods&Cones glasses, focus on complementing the role of the physician – and improving patient outcomes with improved teaching and coaching possibilities.